Cardiac Services Documentation Requirements - JE Part A
Cardiac Services Documentation Requirements
- General Outpatient
- Implantable Automatic Defibrillator (ICD)
- Pacemaker
- Single Photon Emission Computed Tomography (SPECT)
General Outpatient
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
Check | Brief Description |
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Physician/Non Physician (NPP) order or evidence of intent to order | |
Procedure or testing report
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Practitioner progress notes
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Office visit/E&M documentation if billed on same date of service under review | |
Itemization of services | |
Advance Beneficiary Notice | |
Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services) | |
Facility process of how electronic signature is created if using electronic health record |
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.
Documentation Submission
Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.
- Noridian Medical Review: Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT): CID Request
- Level One Appeal: Redetermination Request
Implantable Automatic Defibrillator (ICD)
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
Check | Brief Description |
---|---|
|
Legible handwritten physician and/or clinician signatures
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Valid electronic physician and/or clinician signatures
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Physician or Non-Physician Practitioner (NPP) order for date of service |
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Legible procedure note or report that includes sufficient detail to allow reconstruction of ICD insertion |
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Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided
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Documentation to support patient does not have irreversible brain damage from preexisting cerebral disease |
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Documentation to support a covered indication for secondary prevention as indicated in the National Coverage Determination (NCD) 20.4, if applicable
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Documentation to support a covered indication for primary prevention as indicated in the National Coverage Determination (NCD) 20.4, if applicable
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If ICD was inserted for primary prevention, documentation to support patient is enrolled in either a Food and Drug Administration (FDA)-approved category B investigational device exemption (IDE) clinical trial (42 CFR §405.201), a trial under the CMS Clinical Trial Policy (National Coverage Determination (NCD) Manual §310.1) or a qualifying data collection system including approved clinical trials and registries |
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If ICD was inserted for primary prevention, documentation to support patient does not have:
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Diagnostic test results/reports to support any applicable cardiac findings such as ventricular arrhythmia, the LVEF, a prior MI or prior cardiac intervention
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Documentation to support rationale for a device other than a single lead device
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Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable |
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Office visit and/or evaluation and management (E&M) documentation, if billed on same date(s) of service under medical review |
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Itemization of services |
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Advance Beneficiary Notice of Noncoverage (ABN), if applicable |
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.
Documentation Submission
Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.
- Noridian Medical Review: Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT): CID Request
- Level One Appeal: Redetermination Request???????
Pacemaker
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
Check | Brief Description |
---|---|
|
Legible handwritten physician and/or clinician signatures
|
|
Valid electronic physician and/or clinician signatures
|
|
Physician or Non-Physician Practitioner (NPP) order for date of service |
|
Legible procedure note or report that includes sufficient detail to allow reconstruction of pacemaker insertion |
|
Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided
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|
Documentation to support a covered indication as indicated in the National Coverage Determination (NCD) 20.8.3
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Documentation to support contractor covered indications for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers - Coding and Billing
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Documentation to support rationale for dual chamber device verses a single chamber device |
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Diagnostic test results/reports to support any applicable cardiac findings
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Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable |
|
Office visit and/or evaluation and management (E&M) documentation, if billed on same date(s) of service under medical review |
|
Itemization of services |
|
Advance Beneficiary Notice of Noncoverage (ABN), if applicable |
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.
Documentation Submission
Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.
- Noridian Medical Review: Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT): CID Request
- Level One Appeal: Redetermination Request
Single Photon Emission Computed Tomography (SPECT)
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
Check | Brief Description |
---|---|
|
Legible handwritten physician and/or clinician signatures
|
|
Valid electronic physician and/or clinician signatures
|
|
Physician or Non-Physician Practitioner (NPP) order for date of service
|
|
Legible diagnostic test report and results for date(s) of service billed that includes sufficient detail to allow reconstruction of SPECT scan |
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Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided
|
|
Documentation to support a covered indication as indicated in the National Coverage Determination (NCD) 220.12
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Documentation to support prior diagnostic testing including lab/pathology reports or X-ray/imaging reports if related to SPECT scan
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Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable |
|
Office visit and/or evaluation and management (E&M) documentation, if billed on same date(s) of service under medical review |
|
Itemization of services |
|
Advance Beneficiary Notice of Noncoverage (ABN), if applicable |
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.
Documentation Submission
Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.
- Noridian Medical Review: Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT): CID Request
- Level One Appeal: Redetermination Request
View the Outpatient Prospective Payment System (OPPS) webpage for additional information and resources.
Last Updated Fri, 14 Oct 2022 18:45:06 +0000
Documentation Requirements Disclaimer
The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.
The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.
Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.
The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.